Author + information
- Received June 19, 2018
- Revision received July 2, 2018
- Accepted July 24, 2018
- Published online October 15, 2018.
- Michael F. Morris, MD,
- Mohamad Lazkani, MD,
- Matthew Stanich, MD,
- H. Kenith Fang, MD and
- Ashish Pershad, MD∗ ()
- ↵∗Address for correspondence:
Dr. Ashish Pershad, Cardiovascular Institute, Banner University Medical Center, 1111 East McDowell Road, Phoenix, Arizona 85006.
An 83-year-old woman with New York Heart Association stage III heart failure, severe mitral stenosis, and severe mitral annular calcification was referred for transcatheter mitral valve replacement (TMVR). Pre-procedural computed tomography angiography (CTA) analyzed using TMVR planning software (CircleCVI, Calgary, Alberta, Canada) showed a mitral annular area of 547 mm2. Placing a virtual 29-mm Edwards Sapien S3 valve in the center of the mitral annulus demonstrated a favorable neo-left ventricular outflow tract area; however, a 9 × 4.7-mm gap between the virtual valve and the lateral mitral annulus raised concern for paravalvular leak (PVL) (Figure 1A).
Using a transseptal approach, a 29-mm Sapien S3 (Edwards Lifesciences, Irvine, California) was successfully deployed in the mitral position. The patient’s hemodynamics rapidly deteriorated (Figure 1B), necessitating aggressive pressor support. Three-dimensional transesophageal echocardiography (3D-TEE) demonstrated a normally functioning prosthesis with severe PVL between the Sapien valve and lateral mitral annulus (Figures 1C and 1D, Online Video 1). A 10-mm Amplatzer ventriculoseptal defect (VSD) occluder (St. Jude Medical, St. Paul, Minnesota) was used to plug the PVL because of its small disc-to-waist ratio, with the goal of maximizing sealing while minimizing interaction between the disc and mitral prosthesis (Figure 1E). Follow-up 3D-TEE showed mild PVL (Figure 1F, Online Video 2), and the patient’s hemodynamics significantly improved (Figure 1G). She was ultimately discharged home uneventfully, with persistent mild PVL on 30-day follow-up transthoracic echocardiography.
Severe PVL is uncommon following TMVR in selected patients with mitral annular calcification (1). Three-dimensional–printed models derived from CTA have been used to estimate the risk of PVL before TMVR (2); however, this technique is time-consuming, requires specialized equipment, and is not widely available.
In this patient, software modeling based on the CTA predicted PVL size and location, with excellent agreement to the post-deployment 3D-TEE. Informing the interventional team of the PVL risk allowed them to prepare for percutaneous closure and facilitated early recognition of severe PVL as the cause of hemodynamic compromise after valve deployment, resulting in a favorable patient outcome. Future studies should investigate the use of software-based modeling to predict PVL after TMVR.
Dr. Fang has been a speaker and proctor for Edwards Lifesciences. Dr. Pershad is a speaker for and his institution received an educational training grant from Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 19, 2018.
- Revision received July 2, 2018.
- Accepted July 24, 2018.
- 2018 American College of Cardiology Foundation
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